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| Record Number: |
2464 |
| CIS Descriptors: |
BURNS
CONFINED SPACES
ADHESIVES
PUBLIC WATER SUPPLY
INSULATING WORK
DATA SHEET
SAFETY AND HEALTH TRAINING
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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: Dr. C. Blount, Coroner
PLACE OF INQUIRY: Haileybury
DATE OF INQUIRY : 1991-05-16
INFORMATION ABOUT DECEASED:
NAME: Brian Duff
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Unavailable
ACCIDENT INFORMATION:
DATE OF FATALITY : 1990-06-26
PLACE OF FATALITY: Wellesley Hospital, Toronto
BRIEF CAUSE OF DEATH: Extensive burns.
BRIEF MANNER OF DEATH: He ignited the torch and a flash fire
occurred
from the fumes of the Bakelite Air-Bloc 21 Glue.
ACCIDENT DESCRIPTION:
Brian Duff and his supervisor, Colin Bennett, both employees
of Bennett
Mechanical Installations Ltd. of Millgrove, Ontario, were working
in a
confined space using a WHMIS Class B substance and also an acetylene
torch. The confined space in which the men were working was
a fresh
water pumping station which ordinarily would not be prone to
collecting
hazardous vapours. The men were affixing styrofoam SM insulation
to the
inside concrete walls using Bakelite Air-Bloc 21. This type
of
insulation is that commonly used on the inside and outside of
basements.
This Bakelite Glue is the most commonly used glue for this purpose.
What was unusual was that this was a confined space, that the
men were
not accustomed to doing this type of job and that the inside
walls were
wet from condensation.
On the first day, the men opened a five gallon pail of Air-Bloc
21 and,
noticing the WHMIS Class B label, they performed experiments
to
determine the safety of the product. They dabbed some of it
on the
inside wall of the lower lift pumping station and applied an
acetylene
torch. It burned only as the flame was applied and immediately
went out
when the flame was removed. They concluded from this that there
was not
much danger. They then repeatedly ignited the torch over a six
hour
period on the first day of work to dry the cement wall before
applying
the glue. Half of the five gallon pail was used in that first
day of
work. Then the pail was left in the pumping station overnight.
The
next day, Brian Duff returned alone to the worksite and climbed
down
into the lower lift pumping station. Although there was a strong
odour
of fumes, he lit up the torch. There was a fire and an explosion
which
burned 80% of his body.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. When a worker is working with any hazardous ingredients,
should
automatically have proper ventilation when work is in progress.
2. The individual using any products on jobsite should read
and understand
the label before using it.
3. The handbook named "Occupational Health and Safety Act
and Regulations
for Industrial Establishments" should be written in laymen
terms so
anyone can understand it.
4. There should be more inspectors in the Ministry of Labour,
in the
construction department.
5. Also, more safety training on hazardous material and flammable
should be
available.
COMMENTS ON RECOMMENDATIONS BY CORONER:
These men did not recognize they were working in a confined
space as defined
by the Occupational Health and Safety Act. They did not have
available to
them the material safety data sheet for Air-Bloc 21.
At the inquest it became clear from the testimony of the witnesses
and the
Ministry of Labour representative, Mr. Marlow, that the Occupational
Health
and Safety Act regulations are complex and ambiguous. Technically,
the
lower lift pumping station may not have been defined as a confined
space
until after the naptha based glue was brought into it. Follow
the accident,
four or five places at the water treatment plant were identified
as confined
spaces and labelled.
1. This also refers to recommendation #3. These recommendations
of the
jury are, in my opinion, endorsements of the Occupational Health
and
Safety procedures for dealing in confined spaces. The two men
working
with Air-Bloc 21 had conducted their own flammability test.
It is a
lesson for everyone that repeated ignition of an acetylene torch
in the
presence of Bakelite Glue did not result in a fire or explosion
on the
first day. Unfortunately, confidence was obtained the first
day which
diminished their attention to this danger on the second day
when the
fire and explosion occurred.
2. This recommendation was in the form of a judgement of the
actions of the
two men and the jury complied with my instructions to delete
this from
their verdict.
3. See recommendation #1.
4. Clearly there is a dilemma with the Occupational Health and
Safety
Regulations for Industrial Establishments. The regulations are
extensive, the wording is complex and the definitions are to
some degree
ambiguous. This recommendation refers to that. It seems that
to make
the regulations more specific in regards to the particular circumstances
of this accident would mean making the regulations even lengthier
and
more complex.
5. The Ministry of Labour inspector described the difficulty
and complexity
of training required to understand the Act and how to work safely
in
confined spaces. He testified that he did not really have anywhere
to
refer people to for this training. Lawyers at the inquest recommended
that recognized and widely available training courses on working
in
confined spaces be available for the referral of contractors
and
workers. I believe that this was what the jury intended by this
recommendation.
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